Provider Demographics
NPI:1497734446
Name:CUSTER, JAMES R (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:R
Last Name:CUSTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 8674
Mailing Address - Street 2:1230 E. MAIN STREET
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56002-8674
Mailing Address - Country:US
Mailing Address - Phone:507-625-1811
Mailing Address - Fax:
Practice Address - Street 1:1230 E MAIN STREET
Practice Address - Street 2:MANKATO CLINIC AT MAIN STREET
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56002-8674
Practice Address - Country:US
Practice Address - Phone:507-625-1811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN181422085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
300049064OtherRR MEDICARE
IA90910OtherBCBS
MN3M374CUOtherBCBS
410849339 56001 C025OtherCHAMPUS
IA928747OtherMEDICAID
MN232272200Medicaid
MN764330OtherAMERICAS PPO
MN1600689OtherMEDICA
MNNA2951014708OtherPREFERRED ONE
MN115336OtherUCARE
MNHP24199OtherHEALTH PARTNERS
MN115336OtherUCARE
D48478Medicare UPIN